Nocturnal hypertension and left ventricular hypertrophy in pediatric renal transplant recipients in South India.

HTN after renal transplantation is associated with cardiovascular morbidity. ABPM allows diagnosis of masked HTN and isolated nocturnal HTN. Longitudinal ABPM data in children post-transplant are limited. ABPM was performed in children post-transplant and repeated in 6-12 months. BP indices were used to determine the prevalence of masked HTN, masked uncontrolled HTN (masked HTN in patients on antihypertensive medications), and isolated nocturnal HTN. Linear regression determined the association between LVMI and ABPM indices. Thirty children underwent a baseline ABPM. Ambulatory HTN was present in 25 (83%). Masked HTN was present in 18 (60%) and isolated nocturnal HTN in 13 (43%). Nocturnal ambulatory BP was higher than corresponding daytime BPs (P < .001 for systolic and diastolic) and 25 (83%) had a blunted nocturnal dip. Prednisone dose predicted nocturnal DBP index and DBP load (r2  = .40, P = .024 and r2  = .178, P = .02). ABPM was repeated in 18 patients within 11 (±3) months. BP indices decreased with time, but nocturnal BPs remained higher than daytime (P < .001 for SBP and DBP). Blunted nocturnal dip did not improve. LVH was present in 12 (57%). LVMI was directly related to the nocturnal SBP index (r2  = .377, P = .003) and nocturnal DBP index (r2  = .493, P < .001). We found no association between LVMI and daytime BP indices. The prevalence of masked HTN, isolated nocturnal HTN, and blunted nocturnal dip was high in children with kidney transplants. Nocturnal BP predicted LVMI. Ambulatory BP improved on longitudinal follow-up, but the pattern of isolated nocturnal HTN persisted.

Exclusive breastfeeding practices among mothers in urban slum settlements: pooled analysis from three prospective birth cohort studies in South India.

BACKGROUND: The World Health Organization (WHO) recommends six months of exclusive breastfeeding. Despite documented health, social and economic benefits, the practice of exclusive breastfeeding is quite low and information on influencing factors is limited especially from slum settlements. Our goal is to assess the prevalence and evaluate factors associated with early cessation of exclusive breastfeeding in the first six months of life among mothers in urban slums of Vellore, Southern India. METHODS: We pooled data from three similar birth cohort studies (n = 1088) conducted between 2002 and 2009. Breastfeeding information was obtained soon after birth and then from follow-up home visits conducted once every two weeks by the field workers. Multivariable Cox regression analyses were used to assess factors associated with early cessation of exclusive breastfeeding. RESULTS: The prevalence of exclusive breastfeeding for the first six months was 11.4%, based on prospective data since birth. Results from multivariable analyses revealed maternal education (Adjusted Hazard Ratio [AHR] 1.18 , 95% CI 1.03, 1.35), pucca type of house (AHR 1.25 , 95% CI 1.10, 1.43), two or more number of children in the family (AHR 1.26 , 95% CI 1.10, 1.43), joint family structure (AHR 1.20 , 95% CI 1.02, 1.40) and birth during summer (AHR 1.16, 95% CI 1.01, 1.31) were associated with early cessation of exclusive breastfeeding in the first six months. CONCLUSIONS: Our results indicate that exclusive breastfeeding rates are well below the recommended levels. Educational interventions providing comprehensive breastfeeding information to mothers and their families can be evaluated to assess its effect on improving infant feeding practices.

Natural History of Cryptosporidiosis in a Birth Cohort in Southern India.

BACKGROUND: Cryptosporidium is a leading cause of moderate to severe childhood diarrhea in resource-poor settings. Understanding the natural history of cryptosporidiosis and the correlates of protection are essential to develop effective and sustainable approaches to disease control and prevention. METHODS: Children (N = 497) were recruited at birth in semiurban slums in Vellore, India, and followed for 3 years with twice-weekly home visits. Stool samples were collected every 2 weeks and during diarrheal episodes were tested for Cryptosporidium species by polymerase chain reaction (PCR). Serum samples obtained every 6 months were evaluated for seroconversion, defined as a 4-fold increase in immunoglobulin G directed against Cryptosporidium gp15 and/or Cp23 antigens between consecutive sera. RESULTS: Of 410 children completing follow-up, 397 (97%) acquired cryptosporidiosis by 3 years of age. PCR identified 1053 episodes of cryptosporidiosis, with an overall incidence of 0.86 infections per child-year by stool and serology. The median age for the first infection was 9 (interquartile range, 4-17) months, indicating early exposure. Although infections were mainly asymptomatic (693 [66%]), Cryptosporidium was identified in 9.4% of diarrheal episodes. The proportion of reinfected children was high (81%) and there was clustering of asymptomatic and symptomatic infections (P < .0001 for both). Protection against infection increased with the order of infection but was only 69% after 4 infections. Cryptosporidium hominis (73.3%) was the predominant Cryptosporidium species, and there was no species-specific protection. CONCLUSIONS: There is a high burden of endemic cryptosporidiosis in southern India. Clustering of infection is suggestive of host susceptibility. Multiple reinfections conferred some protection against subsequent infection.

Molecular Identification of Hookworm Isolates in Humans, Dogs and Soil in a Tribal Area in Tamil Nadu, India.

BACKGROUND: Hookworms (Necator americanus and Ancylostoma duodenale) remain a major public health problem worldwide. Infections with hookworms (e.g., A. caninum, A. ceylanicum and A. braziliense) are also prevalent in dogs, but the role of dogs as a reservoir for zoonotic hookworm infections in humans needs to be further explored. METHODOLOGY/PRINCIPAL FINDINGS: As part of an open-label community based cluster-randomized trial in a tribal area in Tamil Nadu (India; 2013-2015), a total of 143 isolates of hookworm eggs from human stool were speciated based on a previously described PCR-RFLP methodology. The presence of hookworm DNA was confirmed in 119 of 143 human samples. N. americanus (100%) was the most prevalent species, followed by A. caninum (16.8%) and A. duodenale (8.4%). Because of the high prevalence of A. caninum in humans, dog samples were also collected to assess the prevalence of A. caninum in dogs. In 68 out of 77 canine stool samples the presence of hookworms was confirmed using PCR-RFLP. In dogs, both A. caninum (76.4%) and A. ceylanicum (27.9%) were identified. Additionally, to determine the contamination of soil with zoonotic hookworm larvae, topsoil was collected from defecating areas. Hookworm DNA was detected in 72 out of 78 soil samples that revealed presence of hookworm-like nematode larvae. In soil, different hookworm species were identified, with animal hookworms being more prevalent (A. ceylanicum: 60.2%, A. caninum: 29.4%, A. duodenale: 16.6%, N. americanus: 1.4%, A. braziliense: 1.4%). CONCLUSIONS/SIGNIFICANCE: In our study we regularly detected the presence of A. caninum DNA in the stool of humans. Whether this is the result of infection is currently unknown but it does warrant a closer look at dogs as a potential reservoir.

Measuring Poverty in Southern India: A Comparison of Socio-Economic Scales Evaluated against Childhood Stunting.

INTRODUCTION: Socioeconomic status (SES) scales measure poverty, wealth and economic inequality in a population to guide appropriate economic and public health policies. Measurement of poverty and comparison of material deprivation across nations is a challenge. This study compared four SES scales which have been used locally and internationally and evaluated them against childhood stunting, used as an indicator of chronic deprivation, in urban southern India. METHODS: A door-to-door survey collected information on socio-demographic indicators such as education, occupation, assets, income and living conditions in a semi-urban slum area in Vellore, Tamil Nadu in southern India. A total of 7925 households were categorized by four SES scales-Kuppuswamy scale, Below Poverty Line scale (BPL), the modified Kuppuswamy scale, and the multidimensional poverty index (MDPI) and the level of agreement compared between scales. Logistic regression was used to test the association of SES scales with stunting. FINDINGS: The Kuppuswamy, BPL, MDPI and modified Kuppuswamy scales classified 7.1%, 1%, 5.5%, and 55.3% of families as low SES respectively, indicating conservative estimation of low SES by the BPL and MDPI scales in comparison with the modified Kuppuswamy scale, which had the highest sensitivity (89%). Children from low SES classified by all scales had higher odds of stunting, but the level of agreement between scales was very poor ranging from 1%-15%. CONCLUSION: There is great non-uniformity between existing SES scales and cautious interpretation of SES scales is needed in the context of social, cultural, and economic realities.

Comparison of fieldworker interview and a pictorial diary method for recording morbidity of infants in semi-urban slums.

BACKGROUND: Cohort studies conducted in low-income countries generally use trained fieldworkers for collecting data on home visits. In industrialised countries, researchers use less resource intensive methods, such as self-administered structured questionnaires or symptom diaries. This study compared and assessed the reliability of the data on diarrhoea, fever and cough/cold in children as obtained by a pictorial diary maintained by the mother and collected separately by a fieldworker. METHODS: A sample of 205 children was randomly selected from an ongoing birth cohort study. Pictorial diaries were distributed weekly to mothers of study children who were asked to maintain a record of morbidity for four weeks. We compared the reliability and completeness of the data on diarrhoea, fever and cough/cold obtained by the two methods. RESULTS: Of 205 participants, 186 (91%) ever made a record in the diary and 62 (30%) mothers maintained the diary for all 28 days. The prevalence-adjusted bias-adjusted kappa statistics for diarrhoea, fever, cough/cold and for a healthy child were 92%, 79%, 35% and 35% respectively. CONCLUSION: Diary recording was incomplete in the majority of households. When recorded, the morbidity data by the pictorial diary method for acute illnesses were reliable. Strategies are needed to address behavioural factors affecting maternal recording such that field studies can obtain accurate morbidity measurements with limited resources.

The first 1000†days of life: prenatal and postnatal risk factors for morbidity and growth in a birth cohort in southern India.

OBJECTIVE: To estimate the burden and assess prenatal and postnatal determinants of illnesses experienced by children residing in a semiurban slum, during the first 1000 days of life. DESIGN: Community-based birth cohort SETTING: Southern India PARTICIPANTS: Four hundred and ninety-seven children of 561 pregnant women recruited and followed for 2 years with surveillance and anthropometry. MAIN OUTCOME MEASURE: Incidence rates of illness; rates of clinic visits and hospitalisations; factors associated with low birth weight, various illnesses and growth. RESULTS: Data on 10 377.7 child-months of follow-up estimated an average rate of 14.8 illnesses/child-year. Gastrointestinal and respiratory illnesses were 20.6% and 47.8% of the total disease burden, respectively. The hospitalisation rate reduced from 46/100 child-years during infancy to 19/100 child-years in the second year. Anaemia during pregnancy (OR=2.3, 95% CI=1.08 to 5.18), less than four antenatal visits (OR=6.8, 95% CI=2.1 to 22.5) and preterm birth (OR=3.3, 95% CI=1.1 to 9.7) were independent prenatal risk factors for low birth weight. Female gender (HR=0.88, 95% CI=0.79 to 0.99) and 6 months of exclusive breast feeding (HR=0.76, 95% CI=0.66 to 0.88) offered protection against all morbidity. Average monthly height and weight gain were lower in female child and children exclusively breast fed for 6 months. CONCLUSIONS: The high morbidity in Indian slum children in the first 1000 days of life was mainly due to prenatal factors and gastrointestinal and respiratory illness. Policymakers need disease prevalence and pathways to target high-risk groups with appropriate interventions in the community.